Form Rx006 - Prior Authorization Request - Miscellaneous

FORM # RX006

Prior Authorization Request Form for Miscellaneous

Member Information

Provider Information

Patient Name ____________________________

Provider Name _____________________________

Cardholder ID ___________________________

DEA Number ______________________________

Date of Birth ____________________________

Address ___________________________________

Address ________________________________

City, State and Zip ___________________________

City, State Zip ___________________________

Phone Number ______________________________

Phone Number ___________________________

FAX Number _______________________________

Pharmacy Information

Pharmacy Name___________________Address__________________Phone______________________

Criteria for Approval

Name and strength of drug requesting

1.

:___________________________________

2. Diagnosis that this is being used for:______________________________________________

___________________________________________________________________________

3. Other medications previously tried and failed:______________________________________

___________________________________________________________________________

4. The patient is unable to take the drug preferred drug because:_________________________

___________________________________________________________________________

5. Is this medication to be delivered through a nebulizer?

Yes

No

6. Please submit additional documentation (labs, chart notes, etc.) supporting use.

Provider Signature _________________________________________ Date _________________________

Fax completed forms to (866) 284-4509.

For Office Use Only

Date/TimeReceived_____________________________________________________________________

ReferenceNumber_______________________________________________________________________

Approved / Denied (Circle One) by _____________________________Date________________________

Date/Time Returned to Provider___________________________________________________________

_____________________________________________________________________________________

If you have any questions regarding this form, contact Prior Authorization Department Toll Free at

(866) 284-4492 or FAX Toll Free at (866) 284-4509.

FOX Rx Care Utilization Management

3375-I Capital Circle NE

Tallahassee, FL 32308

IMPORTANT NOTICE: This facsimile is intended to be delivered to the named addressee and may contain material that is confidential, privileged, proprietary or exempt

from disclosure and applicable law. If it is received by anyone other than the named addressee, the recipient should immediately notify the sender at the address and telephone

number set forth herein and obtain instructions as to disposal of the transmitted material. In no event should such material be read or retained by other than the named

addressee, except by express authority of the sender to the named addressee.